5Contagion and Interruption in Practice

The previous chapters explored the contagion of violence in
the context of the pattern of spread, the possible mechanisms at both
the individual and social levels, and the factors that might reduce or
exacerbate exposure and transmission. Drawing from this framework,
speakers also examined potential processes of interruption or
mitigation. Speakers at the workshop also explored some real-life
examples of this contagion at work, bringing all of these concepts
together, as well as interventions currently in practice that seek to
reduce it.

THE CONTAGION IN ACTION

Speakers Jason Featherstone of Surviving Our Streets and Zainab
Al-Suwaij of the American-Islamic Congress both spoke of recent
occurrences in which single acts of violence sparked an epidemic in
very different ways.

UK Riots

On August 4, 2011, Mark Duggan was shot and killed by police in the
Tottenham neighborhood of North East London, England. Two days
later, friends and family marched to the police station to obtain
information regarding the shooting. After several hours of silence,
patience ran out, and a series of altercations led to the
overturning and burning of several police cars. Captured on video,
the burning cars became a symbol for those who felt frustration
around relationships with law enforcement, the current economic
climate, and various political austerity measures related to
education and public services. In addition, Mr. Featherstone noted,
residents of Tottenham had a preexisting ingrained mistrust of law
enforcement, related to perceived injustices and deaths in police
custody over the previous decade. Mr. Featherstone also showed
several video clips and commented on the sense of relief and
anticipation expressed by participants of the violent acts that
followed the initial event. Notably, many of the organizers and
participants belonged to groups with traditional rivalries, which
were set aside in these events. Following the burning of the cars,
violence spread throughout Tottenham, London, and then other parts
of the United Kingdom over the next several days. Mr. Featherstone
noted that rioters were diverse and did not fit the
“traditional” image.

Calls to commit violence were sent via social media to those within
close geographical proximity as well as those in other locations
outside the United Kingdom. Footage of the rioting and looting was
shown constantly on television, and made headlines in major
newspapers. Violence spread through the country for 5 days, and then
subsided as police presence in the streets ramped up significantly,
and large numbers of arrests were recorded.

Through video clips and his own reflections, Mr. Featherstone painted
a complex story of not just violence throughout the country, but a
sense of resentment, frustration, and inequality that had bubbled
over. Previously that year, large antiausterity protests had been
held, with little to no relief presented. In one map he showed,
there was strong geographical correlation between the violent
incidents and areas of deprivation. While gang violence was cited as
a major factor in the violence, Mr. Featherstone argued that only a
small number of rioters were members of gangs, and even then they
behaved in ways not typical of gang rivalries. Throughout his
presentation, Mr. Featherstone echoed a number of elements that had
been noted previously by other speakers, specifically the importance
of the social context, the dynamics of groups, the emotional
response to witnessing violence, and the potential for epidemics to
peak and then decline, in describing the complexities of this
event.

In discussing potential interventions to reduce violence related not
just to the riots, but the preexisting social and economic
conditions, Mr. Featherstone noted the importance of empowering
individuals to not identify as victims or perpetrators. He also
noted the importance of developing community—law enforcement
relationships to build trust. He stated, for example, that in the
case of Mark Duggan, some of the immediate incendiary violence might
have been prevented if police had spoken to the family and conveyed
a sense of working with the community. Speaker and planning
committee member Charlotte Watts of the London School of Hygiene and
Tropical Medicine shared concerns that while interruption programs
reduced street violence, they did not address the underlying issues
that exacerbated the tense situation. Mr. Featherstone concurred,
and noted that such reforms would take years to implement, while
reducing retaliatory violence could be an easier issue to address in
the short term.

The “Arab Spring” and Iraq

The “Arab Spring” is a term coined to describe
events across the Middle East and North Africa (MENA)
characterized by wide-scale populist uprisings against
dictatorial governments. While many of the events are
continuing, the uprisings have been likened to the
“Autumn of Nations” that occurred in Eastern
Europe in 1989. The singular event that was said to have begun
the wave was the self-immolation of Tunisian Mohamed Bouazizi on
December 18, 2010, as an act of protest against police and
government corruption. Immediately in response, protests cropped
up throughout Tunisia, and eventually led to the toppling of the
government. A month later, similar protests swept through Egypt,
and spread to Bahrain, Libya, Syria, and Yemen. Protests also
occurred in Algeria, Iran, Iraq, Jordan, Morocco, and Oman and
continued to spread through the region.

Unlike the UK riots, a contained trajectory of events has not
presented itself in the MENA region. Additionally, many forms of
violence have been reported, not limited to political conflict,
but also spikes in interpersonal violence (e.g., sexual
harassment). Ms. Al-Suwaij noted that as collective violence has
destabilized communities, it has normalized the use of other
types of violence, echoing comments by other speakers about
different “syndromes” of violence.

Ms. Al-Suwaij also spoke of her experience with violence in Iraq,
going back to her time as a student during Saddam
Hussein's regime, and the protests that occurred then,
reminiscent of those occurring now. She noted that much of the
violence is sectarian or interethnic and she is exploring
opportunities to reduce such violence. She established
Ambassadors for Peace, a program she has sold with varying
degrees of success to community and religious leaders in various
locations in Iraq. In describing her experience, she noted that
much of the conflict that occurs is related to simmering
resentment, and is often set off by something innocuous, such as
two children arguing over a soccer game. Thus her approach to
mediating conflict draws heavily on the Cure Violence (formerly
known as CeaseFire) model, and aims to interrupt retaliatory or
tribal violence related to preexisting grievances. She noted
that in one of three areas in Basrah, in which her program has
been operating for 3 years, intertribal violence has been
reduced to zero. She also discussed plans to scale up the
program and move to other areas.

Ms. Al-Suwaij also noted challenges in the Ambassadors for Peace
program, notably continuing political violence, lack of trust in
law enforcement (an issue that is being addressed), and the
inability to intervene as successfully in other forms of
violence, such as domestic violence. She noted that it is still
taboo to talk about domestic violence, and much of it is vastly
underreported. When her interrupters hear about violence in
families, they attempt to address it, but the existing legal
structure prevents significant addressing of the issue. She also
noted that, in peer group sessions of only women, some
conversation around gender equality, gender norms, and violence
against women is introduced.

INTERRUPTION AND APPLICATION

Panelists in the afternoon of the second day described some
approaches to interruption, and challenges and opportunities to
scale up. Before the panel, participants watched the documentary
film The Interrupters, which chronicles the work of
four violence interrupters as part of the CeaseFire Illinois
initiative (CeaseFire Illinois is a Cure Violence program).
CeaseFire Illinois, the program initially developed by speaker and
planning committee member Gary Slutkin of the University of Illinois
at Chicago, uses individuals called interrupters to halt the further
spread of violence. These interrupters are respected in the
community and usually have some history of violence themselves. They
intervene when violence occurs, usually to prevent further spread or
to prevent retaliation. They also work with high-risk individuals in
the community to reduce tensions and other conditions that might
result in violence.

In introducing the film, facilitator and planning committee member
Brian Flynn of the Uniformed Services University School of Medicine
explored some key concepts in the natural cycle of violence. He
noted, referencing Stephen Pinker's book The Better
Angels of Our Nature, that traditionally violence is
lower in urban versus rural areas. Pinker's premise is that
rule of law and governing systems are responsible for reducing
violence, but in areas where violence spikes, people may not feel
that rules apply to them, or systems are capable of upholding
justice. Dr. Flynn also stated that, per Pinker, as women become
more empowered, violence decreases as well. He urged the audience to
consider these points as they watched the film. Finally, he posited
that as previous discussions highlighted the observation of violence
(either near or far) as a risk factor for future perpetration or
victimization, perhaps the observation of violence interruption
could further the spread of prevention as well.

Community-Based Intervention

Following the film, speaker and CeaseFire Illinois program
director Tio Hardiman spoke about the experience of the
interrupters, the program, and potential for scaling up. He gave
four examples of recent events, which transpired within an hour,
that required the intervention of the interrupters: (1) an
incident involving a man who stole his girlfriend's pain
medication, prompting threats and retaliation from her sons; (2)
an incident involving two men in a territorial altercation that
had expanded to involve several others; (3) two men arguing over
a woman; and (4) two men involved in an altercation over the
sale of drugs, which the interrupters did not mediate, though
they did ensure that the situation would not result in violence.
Mr. Hardiman went on to note that CeaseFire interrupters worked
with 1,100 high-risk individuals and mediated 800 conflicts in
2011.

In Chicago, homicide is the leading cause of death for 15- to
24-year-olds, and Mr. Hardiman estimated that in the past
decade, potentially 5,000 homicides have occurred. He described
the circumstances in which many young individuals involved in
violence and crime grow up with the mentality of needing to
shoot first, to not be victimized, and to find ways to leave the
structural poverty of family neighborhoods behind. He noted that
violence is often normalized in these situations, and has
lasting effects in a number of settings, such as schools, where
children have difficulty learning because of fear of events
outside of school. He noted that businesses often leave
neighborhoods because of the destabilizing effect of violence.
He also noted the importance of addressing issues on “the
front end,” that is, intercepting rumors of potential
violence, and intervening before it occurs.

The Cure Violence model, in addition to interrupting the spread
of violence, also aims to address social and group norms and
behaviors around violence. Some of the work involves reaching
out to individuals and assisting them with employment or
education. In addition to the work of the interrupters, outreach
workers are constantly in communities monitoring the pulse and
providing educational opportunities. The interrupters also
liaise with local law enforcement and mediate conflicts with
victims of shootings who end up in hospitals.

School-Based Intervention

Speaker Patrick Burton of the Center for Justice and Crime
Prevention in South Africa shared his experience with working in
schools in South Africa to reduce violence in youth. The
program, in particular, was interested in preventing
“low-level,” high-frequency violence such as
bullying and dating violence, and in improving academic
outcomes. He also noted the importance of addressing the social
milieu and how students relate to one another in terms of
forming more positive relationships. Dr. Burton spoke of data
issues, particularly a lack of insightful, robust data, often
due to non-reporting because of fear of the perception that
schools are not safe. Despite this, he estimates that about 15
percent of students had experienced violence in the previous 12
months.

In describing the approach, Dr. Burton explained the
“whole-school” approach, in which the program
works with all stakeholders in school-based learning, including
the teachers, students, parents, school governing body, and
policy makers. It is also embedded in communities, working with
families and homes in which students are experiencing or at risk
of experiencing violence. The program places responsibility of
identifying priorities and interventions on the schools, while
providing guidance on response and prevention. Schools are shown
how to identify safe and unsafe spaces within schools, how to
manage and respond to reports of violence or threats of
violence, and how to demonstrate action on such reports.

Dr. Burton went on to explore some of the challenges faced in the
program and in scaling up. In 2005, the program was piloted in
85 schools; it is now active in just over 2,000 schools
nationally. It is also currently being developed to other sites
outside South Africa. Two formal outcome evaluations have been
performed, and several informal process evaluations. He noted
challenges in accountability, such as who is responsible for
violence occurring and for response or lack thereof; ownership,
management, and institutionalization. These challenges are
especially difficult because effective school managers are often
moved around. There are also challenges in supporting schools,
whose primary task is education, to also work toward providing
safe environments and the shared vision of what a safe school
means—not just physical security.

The social context in South Africa has played a strong role in
the exacerbation of violence, including a sizeable percentage of
students (16 percent) having family members who have committed
acts of violence and are currently incarcerated. Mr. Burton
noted that the success of the school intervention program has
been dependent on the integration with home-based efforts to
address family violence. In the most successful sites, where
there has been integration with parenting programs and the
school's efforts, school-based violence has dropped
significantly, some down to zero.

Family Violence Prevention and Interruption

In thinking about interrupting violence at the family level,
speaker Valerie Maholmes of the Eunice Kennedy
Shriver National Institute for Child Health
& Human Development explored a series of studies being
funded by her institute. She noted particularly how much of the
research focuses on early development, and the importance of
both the research and that age group in framing violence
prevention. The first study she noted is that of Judith
Langlois, which looks at the development of appearance-based
stereotypes in children. Children naturally differentiate
between more and less attractive appearances, but it is the
observation of differential behavior by parents that ingrains
value in appearance. Throughout life, these biases are more
firmly established through repeated observation, and serve as
barriers to receptivity of counterstereotypic messaging. Dr.
Maholmes noted that the important implication here is that this
work may prompt the development of interventions that ameliorate
negative judgment based on attractiveness, and learning about
these mechanisms may help inform evidence-based practice.

Dr. Maholmes went on to describe an intervention in India
designed by Suneeta Krishnan, called DIL-MIL (Hindi:
“hearts together”), which leverages the role of
mothers-in-law to reduce violence against daughters-in-law. She
noted that women are vulnerable to gender-based violence because
they often have to acquiesce to the marital family, and that
efforts to empower women must take into account social and
family dynamics. She noted that mothers in law are crucial entry
points, but people do not often realize that their role can be
pivotal. This intervention brings these dyads together and,
using social-cognitive theory, educates and empowers the women
to reduce gender-based violence. Finally, Dr. Maholmes described
a study by Amy Marshall looking at aggression within families,
disaggregating interparental aggression (IPA) and
parent-to-child aggression (PCA) to see if the two co-occur, if
PCA is an outcome of IPA, if either or both have a
“spillover” effect to violence between other
family members (i.e., sibling-to-sibling) or outside the
family.

In response to a question from a participant, Dr. Maholmes noted
that intergenerational transmission of violence is strongly
influenced by the normalization of violent behavior within
families and the internalization of such by girls. She posited
that useful interventions in breaking this cycle would need to
include messaging around self-worth and self-esteem, as well as
the ability to show other types of relationships.

Trauma-Informed Approaches

Speaker John Rich of the Drexel University School of Public
Health spoke of the importance of the trauma-informed approach
to violence prevention, noting that trauma is at the center of
violence and that “hurt people hurt people.” He
also referenced other words from Sandra Bloom from the Drexel
University School of Public Health about reframing inquiry from
asking about what is wrong with someone to asking what happened
to someone, knowing that early adversity and stress can have
deleterious effects. In thinking about how to approach the
interruption of violence in the health care setting, Dr. Rich
noted the importance of examining these roots of trauma because
patients who present with physical injury often have
psychological injury as well. Failing to address those secondary
injuries runs the risk of retraumatizing the individual. He also
pointed out that the “injured” included not only
the individual with the injury, but those who might have
witnessed the violence, and potentially even those who work with
the injured and traumatized; thus, understanding trauma across
populations informs violence prevention at larger scales.

Dr. Rich also stated that violence is a recurrent disease, with
high risks of recurrence. He cited some studies that show, 5
years out, that 45 percent of those with serious injury have
experienced another serious injury, and 20 percent of them are
dead. Of that 20 percent, 70 percent had substance abuse listed
as a contributory cause. In other situations he referenced,
young men who present with serious injury have high rates of
posttraumatic stress disorder (PTSD), hypervigilance, and
history of childhood adversity. Dr. Rich also pointed out that
perpetrators are also at risk of PTSD symptoms, so it is not
just victims.

Hospital-based interventions that are trauma-informed have been
known to work. Shock Trauma in Baltimore has an intervention
that has shown a reduction in involvement in the criminal
justice system for its patients. Dr. Rich explained that
hospital-based interventions are about recognizing the
additional trauma faced, as a bigger picture approach to
reducing violence. The interventions screen for past trauma and
provide guidance in navigating systems, both medical and
criminal justice, which might also potentially retraumatize. It
also provides an outlet for aggression or rage, usually
conversation with a case worker, as a means to reduce the
potential for retaliatory violence. Finally, he noted it is
important to include direct trauma recovery assistance as well,
citing a few in use with evidence to back effectiveness.

Most salient though, Dr. Rich noted, is system-wide
transformation into treating trauma as a cause and not just as
an outcome, and to reflect on the comorbidity of different forms
of violence, in the context of trauma. In addition, educating
the community on trauma and its effects would provide a more
nuanced perspective, including structural violence and
intergenerational oppression. He noted especially that moving
the conversation out of just hospitals and into a number of
partnering organizations as well as the community would be the
most effective approach.

Key Messages Raised by Individual Speakers

The spread of violence has a number of complex
factors, including social and contextual
undercurrents that fuel frustration, anger, and
mistrust in systems (Featherstone, Flynn, Rich).

Finding a key leverage or entry point could optimize
interventions (Hardiman, Maholmes).

Recognizing and addressing the fundamentals of trauma
provides a holistic approach to hospital- and
community-based interventions (Hardiman, Rich).

Scaling up requires attention to a number of factors,
including accountability and finding and working
with partners (Al-Suwaij, Burton, Hardiman).

Copyright 2013 by the National Academy of Sciences. All rights
reserved.